Questions and Answers Relating to Avian Influenza
U.S. Embassy New Delhi
(updated 07 June 2007)
1. How do I know if I have Avian Influenza?
Symptoms of H5N1 avian influenza are not unlike the symptoms of other forms of flu: fever, cough, sore throat and muscle aches. At later stages of the disease, the patient may suffer severe respiratory complications. If you have these symptoms, you are unlikely to have H5N1 avian influenza unless you have been in close contact with infected birds. Nevertheless, you are encouraged to see a doctor for appropriate diagnosis and treatment.
The U.S. Embassy and Consulates in India maintain lists of local doctors and hospitals. Please see http://newdelhi.usembassy.gov (for the New Delhi consular district), http://mumbai.usconsulate.gov (for the Mumbai consular district), http://chennai.usconsulate.gov (for the Chennai consular district) or http://kolkata.usconsulate.gov (for the Kolkata (Previously Calcutta) consular district). On any of these webpages, click on "U.S. Citizen Services."
2. How do people become infected?
Currently, direct contact with infected poultry, or surfaces and objects contaminated by their feces, is presently considered the main route of human infection. To date, most human cases have occurred in areas where many households keep small poultry flocks, which often roam freely, sometimes entering homes or sharing outdoor areas where children play. As infected birds shed large quantities of virus in their feces, opportunities for exposure to infected droppings or to environments contaminated by the virus are abundant under such conditions. Moreover, because many households in Asia depend on poultry for income and food, many families sell or slaughter and consume birds when signs of illness appear in a flock, and this practice has proved difficult to change. Exposure is considered most likely during slaughter, defeathering, butchering, and preparation of poultry for cooking.
3. Has a vaccine been developed against the virus yet?
Yes, clinical trials of a Vietnam strain of H5N1 human vaccine have demonstrated safety and efficacy. Further work is required to determine the proper dosing and potential boosting of adjuvants. The US Department of Health and Human Services (HHS) has placed an initial order for this vaccine and stands ready to order more once it is available. It remains to be seen, however, whether this vaccine will be effective against other H5N1 strains currently circulating, let alone against a pandemic strain that has undergone genetic change from the currently circulating virus. Once a new pandemic virus has emerged, large-scale production can begin of a more specific pandemic vaccine. Supplies sufficient to significantly impact a rolling pandemic may not be available for at least six months. Although the current global production capacity is inadequate for the expected vaccine needs, alternate and more efficient technologies for vaccine development are being vigorously pursued.
4. Will getting a flu shot this year afford any protection against a future pandemic avian influenza virus?
No. The annual influenza vaccine is targeted against specific influenza strains predicted from the previous year. Yearly seasonal flu shots are not even effective against next year's influenza strains, let alone against a future emerging pandemic strain. Of course medical authorities encourage everyone to have the seasonal vaccine every year to prevent flu and to help prevent the emergence of a more pathogenic H5N1 strain that could be transmitted from human to human.
5. Is there any other treatment for Avian Influenza?
Based upon limited data, the Centers for Disease Control and Prevention (CDC) has suggested that the anti-viral medication oseltamivir (brand name "Tamiflu") may be effective in preventing or treating avian influenza. Tamiflu is not a medication that is effective when taken only once, but rather generally is prescribed in a series of doses over several days. The World Health Organization (WHO) has provided specific recommendations for Tamiflu dosages for children and adults at http://www.who.int/csr/disease/avian_influenza/
guidelines/oseltamivir2006_03_17/en/index.html.
6. Should I begin taking antiviral medications such as Tamiflu if I'm planning a visit to another country?
No, the CDC specifically states at this time persons traveling to countries with Avian Influenza cases in birds, poultry or humans do not need to take Tamiflu prophylactically. If you become ill in any way while in the country, you should seek medical advice immediately. Travelers to any country that has reported cases of H5N1 among birds or humans should consider scheduling an appointment with their health care provider before traveling to discuss risks for potential exposure to H5N1. Only you and your health care provider can determine that risk and what the most appropriate precautions are for you.
6. Can I obtain Tamiflu in India or Bhutan, or alternatively from the U.S. Government?
Limited amounts of Tamiflu, manufactured by the Swiss-based pharmaceutical Roche, are reportedly being made available in India through the company's Indian distributor Taksal Pharma Privated Limited. In addition, two Indian-based pharmaceutical companies, Hetero Drugs and Cipla, have been granted permission by the Government of India to manufacture generic versions of the drug in India (called "oseltamivir"). The generic oseltamivir being manufactured by Hetero and Cipla will be aimed both at the Indian market as well as the export market. The Indian government is expected to place a large order with Hetero for supplies of oseltamivir.
Limited amounts of Tamiflu are now available in selected hospital-affiliated pharmacies in India. The Indian government is determining whether to limit the drug's availability only to hospital-affiliated pharmacies (which generally dispense only with a physician's written prescription), or to allow sale of the drug in other commercial pharmacies as well (many of which sell drugs without a prescription).
In the event of a full-blown pandemic, pharmaceutical companies could possibly face difficulties in importing the necessary ingredients to manufacture the drug in large quantities given the competing demand for these ingredients from pharmaceutical companies in other countries.
The Embassy has no information regarding the availability of Tamiflu in Bhutan.
American citizens traveling or living abroad may wish to consult with their private physician (in the U.S. or abroad) about obtaining Tamiflu. Americans living in India who do not currently have a relationship with a local physician, are encouraged to do so. For lists of local doctors, please see question 1, above. Americans should be aware of the potential health risk posed by counterfeit drugs, including those represented as Tamiflu, particularly by internet scam artists. In the event of an influenza pandemic, the ubiquity of counterfeit Tamiflu scams is expected to increase dramatically.
The U.S. Embassy in New Delhi and the U.S. Consulates in Mumbai, Chennai and Calcutta are pre-positioning Tamiflu for eligible U.S. Government employees and their families serving abroad. At this time, there is no provision or legal authority that allows the U.S. government to provide private American citizens traveling or living abroad with medications, including in the event of a pandemic.
7. Why isn't the U.S. Government providing Tamiflu to private Americans overseas?
The U.S. Department of State lacks the legal authority to provide any type of medication, including Tamiflu, to private American citizens. State Department physicians and medical staff have authorization to treat only those official employees, and their families, who are under Chief of Mission authority-i.e., who are employed directly by the U.S. Government at the U.S. Embassy in New Delhi, or the U.S. Consulate in Mumbai, Chennai or Calcutta.
8. Will you evacuate Americans in the event of a pandemic?
Current medical thinking suggests that a "stay in place" response to a pandemic may be appropriate in certain countries or regions. In this scenario, people would be advised to exercise "social distancing" and avoid any form of public gathering where transmission of the disease could occur. Airplanes are a common venue for human-to-human transmission of viral infections due to proximity of travelers and recycling of air within the cabin. It is also possible that the United States will not accept commercial flights from cities or countries known to have outbreaks of human-to-human transmission cases. Travelers who are not comfortable with this scenario should consider these factors when making their plans.
Whether the U.S. Government evacuates anyone will depend on a variety of factors specific to individual countries. Each U.S. Embassy has been asked to develop a contingency plan in the event of a pandemic, and to identify events that might prompt them to send employees and/or their dependents out of the country, assuming such travel is possible. Should the decision be made to send Embassy/Consulate employees and/or their dependents out of a country, we will communicate this to the private American community via a "warden message" so that people can plan accordingly (see the last item below about receiving warden messages). As in any other crisis, we will assess the availability of commercial transportation, the ability of people to travel to the United States or a third country, and other related factors in deciding on appropriate actions to assist Americans.
9. Is it safe to eat poultry and poultry products in India and Bhutan?
Yes, though certain precautions should be followed in countries currently experiencing outbreaks. In areas free of the disease, poultry and poultry products can be prepared and consumed as usual with no fear of acquiring infection with the H5N1 virus.
In areas experiencing outbreaks, poultry and poultry products can also be safely consumed provided these items are properly cooked and properly handled. The H5N1 virus is sensitive to heat. Normal temperatures used for cooking (70oC in all parts of the food) will kill the virus. Consumers need to be sure that all parts of the poultry are fully cooked (no "pink" parts).
As always, the outside of the eggs should always be washed thoroughly, and that all eggs should be properly cooked (no "runny" yolks). Consumers should also be aware of the risk of cross-contamination. In areas experiencing outbreaks in poultry, raw eggs should not be used in foods that will not be further heat-treated as, for example by cooking or baking. Therefore, caution must be taken when eating in restaurants which may be serving sauces or salad dressings containing undercooked egg products. Avian influenza is not transmitted through cooked food. To date, no evidence indicates that anyone has become infected following the consumption of properly cooked poultry or poultry products, even when these foods were contaminated with the H5N1 virus.
Juices from raw poultry and poultry products should never be allowed, during food preparation, to touch or mix with items eaten raw. When handling raw poultry or raw poultry products, persons involved in food preparation should wash their hands thoroughly and clean and disinfect surfaces in contact with the poultry products. Soap and hot water are sufficient for this purpose. With respect to kitchen utensils, it has been shown that the virus is sensitive to most detergents so that soap and not just water is important in killing the virus. Use a separate cutting board for poultry and carefully wash the board as well as utensils after use. You can follow this with a sanitizing solution of bleach: 1 TBSP bleach to 4 liters of water.
Guidance on handling food to avoid spreading the virus is available on the websites for the CDC, the U.S. Department of Agriculture, and the World Health Organization (WHO).
10. Where can I safely buy poultry products?
At this point, we advise that you do not go to live poultry markets or meat markets where chickens are butchered. Instead, you buy poultry already prepared and wrapped in refrigerators in stores. We also advise you avoid going to any poultry farms (large or small) in India or other countries that have had avian influenza outbreaks.
11. Do High Efficiency Particulate Air (HEPA) filters on airplanes offer protection?
Yes, if they are true HEPA filters, but many planes are not equipped with them. Airplanes are a common venue for human-to-human transmission of viral infections due to proximity of travelers and recycling of air within the cabin. You should not travel if you are ill or have a fever. If a neighbor is coughing or appears ill near you, move and tell the flight attendant. This is particularly important if you are flying from a country that has documented avian influenza cases in humans.
12. If I live in an area where diagnostic tests for Avian Influenza are not available and I become sick with flu like symptoms, should I fly out?
If you develop influenza symptoms and are in a country known to have H5N1 among birds and/or humans, it is important to get immediate medical care. For this reason, you should visit a local doctor for treatment, rather than waiting to visit a doctor back in the United States.
In any event, it is likely that governments will respond to a pandemic by imposing public health measures that restrict domestic and international movement. Thus, Americans should be prepared to "stay in place" in the event of a pandemic.
13. As a private American citizen living overseas, what can I do today to help prepare myself and my family for possible bird flu pandemic?
Several simple measures can be taken now that will put you in a better state of readiness should such a pandemic occur. First of all, as suggested for reasons other than just bird flu, purchase enough non-perishable food, water, and personal supplies for your family for a prolonged period--certainly no less than two weeks. Store it in a place where you will not be tempted to break into it for everyday use; if you are asked to "stay in place" or remain in quarantine, these supplies will be vital. Along with those supplies, buy several boxes of tissues for use should someone come down with a respiratory virus. Also, purchase two thermometers (one to be used by a symptomatic person, and the other for the remaining members of the family). If you are living overseas due to work or education, contact your sponsor and find out what plans they may have regarding repatriation or evacuation; they may also have advice for you about procuring influenza immunization, avian influenza immunization (if and when available), anti-viral medication (such as Tamiflu), and other suggested measures as they arise.
Even basic measures can make a difference. Thus, you should encourage regular hand-washing among family members, and discourage touching of the eyes/nose/mouth. Personal hygiene measures to minimize the impact of sneezes and coughs will go a long way in lessening your risk of catching many viruses, not just the bird flu virus.
A useful checklist of preparation steps individuals and families can take to prepare for a possible pandemic is available at http://pandemicflu.gov.
14. Are children more susceptible?
The WHO and the CDC believe that children may be more susceptible due to their increased proximity socializing at schools and day care centers, as well as being more likely to come into contact with poultry or bird fecal matter during their play habits. It is unknown whether immunity differences in children have any significance, since we presume that the vast majority of humans have no immunity against the H5N1 virus.
15. Can my children visit zoos?
Yes, but it is recommended that they do not visit the aviary section(s) of the zoo.
16. How will I know if the U.S. Government updates its recommendations for Americans living in or traveling to India or Bhutan?
The U.S. government will share with members of the private community material actions taken with respect to its own employees, such as a partial or full evacuation of Embassy and Consulate American personnel and/or their dependents. We will also notify registered Americans via e-mail if our travel recommendations change on account of Avian Influenza. In order to receive messages of this nature, generally known as "warden messages," you must register your presence in India or Bhutan at https://travelregistration.state.gov/ibrs. A link to this registration site also appears on the Embassy website at http://newdelhi.usembassy.gov (click on "Registering Your Presence in India").
17. How will I know about travel advisories to countries other than India and Bhutan?
With respect to countries with known outbreaks of avian influenza, travelers are advised to avoid contact with live birds, chickens, ducks, turkeys and geese and their feces, feathers and pens if at all possible. Children, in particular, should be warned and precautions enforced. Pet birds should not be kept. If preparing poultry, cook it well done before eating. Avoid cross contamination of other foods by use of separate kitchen utensils and surfaces exposed to raw poultry. Wash hands with soap and water after any poultry contact. Be sure, if possible, that poultry does not live near your housing area. Do not transport live or dead poultry even if it appears to be healthy. Avoid poultry products from areas of infected birds. If you must travel to infected areas and work directly with infected birds, poultry or humans, hand washing and shoe and clothing cleaning should be an immediate priority. Be sure to wear personal protective equipment (such as gloves, a special N-95 mask, goggles and a disposable gown) if you must be in contact with the birds/poultry in enclosed environments where aerosolization of the small virus particles may occur. Observe yourself for the development of any respiratory or gastrointestinal symptoms after the visit and check your temperature for a week afterwards, and contact a physician if you have any questions.
You should monitor these organizations' respective websites for updates. Please click here for links to these websites.